Stroke Unit, NHSL carves historic niche in mechanical clot retrieval

7.15 a.m February 27, 2018: A 56 year old female from Kadawatha is brought to ward 15 of the newly updated Epilepsy building at the National Hospital Colombo. Unable to talk, her right side showing signs of weakness, she displayed the classic symptoms of a sudden stroke.

On arrival , a trained team goes into immediate action. Moving fast with the disciplined precision of an army drill operation, they lose no time in preparing the patient for the treatment on which her life depends, having ruled out the interventions they usually carry out on Emergency treatment patients due to heavy bleeding due to a large clot from the aorta to the brain.

“ We tried to experiment with the stroke busting method but that was not an option. The second option was to retrieve the clot “ said Secretary, Sri Lanka National Stroke Association, & Consultant Neurologist Dr. Gamini Pathirana in a telephone interview. He said, he then directed the patient to Interventional radiologists Dr Prasad De Silva, Head of the Department of Radiology and colleague Dr. P. Bandaranayake.

But, after performing an urgent CT scan and other tests the radiologists found that chemical clot retrieval method is not suitable due to possible bleeding as a complication. So, instead they opted to remove the clot physically.

Not surgery

”What we did was not a surgery. There was no cutting and opening up the patient. We used the minimal invasive approach, ” Dr De Silva explained to the Sunday Observer, Thursday, in a telephone interview.

What he and his colleague Dr Bandaranayake did was to remove the clot by inserting a catheter.

“The patient was put on the operating bed at 9.45 a.m, and by 9.50 a.m we were at the clot. Suction and catching the clot was more complicated but by 10.15 a.m the clot was out of the brain. “We went into the right groin to enter into the aorta which is the main blood vessel , and then the neck vessel and finally the brain.”

The entire procedure had taken them just 25 minutes to restore the blood supply to the brain.

“We had to wait another 15 minutes to carry out another angiogram to make sure the artery didn’t go into spasm and the patient was then ready to leave the angio-table,” he said.

So, how was the patient when she recovered after the procedure? we asked. “When she arrived she seemed confused and unable to obey our commands. After the procedure she seemed much more alert to her surroundings and her speech was much better. There was a little damage, which was there beforewe interviewed but if we hadn’t interviewed, her entire right side with speech would have been destroyed. Her brain is recovering slowly now, and she will soon be ready for rehabilitation.”

Reflecting on the preparations leading to the procedure, from the OPD level on he said, everyone had given them their unstinting support. “ We the interventional radiologists are right at the end of the line when it comes to making the correct ETU decision”, he said , thanking the hospital administration, deputy Director General NHSL Dr Kumar Wickramasinghe , and Senior Neurologists Dr Padma Gunaratna and Dr Gamini Pathirana for their support. He also complimented the family of the patient for bringing her direct to the National Hospital. “For a stroke patient, every minute counts. The sooner they are brought to us the better the outcomes of any treatment and avoidance of complications” he emphasized.

Looking back on preparations leading to the history making event, he said, “We have been trying to put everything in place for one whole year, getting this building properly equipped but had to wait due to various hiccups. Now that we have put them in place we can continue our efforts to save stroke patients’ lives in the future”.

Senior Neurologist Dr Padma Gunaratna echoing his sentiments said , “This procedure is usually done within six hours of onset. As the patient had been brought early it gave us time to carry out our pre procedure preparations.” She said, this particular procedure had not been in place in a state sector hospital until now . “That’s what makes the procedure unique”, she noted. Only the private sector has carried out one or two of such procedures at a high cost, over a million rupees for catheters injections, etc.”, she said.

She informed that the patient is presently under her care . “It will take at least two weeks to get her back to normal,” she said. ‘She had a major clot block in her main vessel . When a clot originates from a large vessel they are usually big clots and patients develop severe symptoms which can be fatal. Nine percent of Sri Lankan women die in the first few days of admission if they are not brought to us in time. Luckily for her, this patient survived and the operation was a success because her family took the right decision in bringing her to us early,.” she pointed out.

Plugging gaps

Asked the most pressing needs of the hospital right now, she said, “On our part we have done everything we could . What we need is to increase the beds of patients . The work on the Mulleriyawa Hospital Stroke Unit in ward 16 must be expedited, and all leading state hospitals must be equipped with facilities for treating stroke victims.” Education and awareness raising programs for the public at large was also an urgent need she said, as many people were unaware of the symptoms of stroke onset, such as, sudden weakness of the limbs.